The purpose of this study was to examine the relationship between written knowledge, simulated clinical practice and actual clinical practice related to lead placement for cardiac monitoring. In order to accurately identify cardiac dysrhythmias, placement of leads in the correct position is essential. As nurses have primary responsibility for placement of leads, their knowledge is critical to the dysrythmia detection process. Therefore, nurses were evaluated via a written knowledge test and by demonstration on a model and on patients. Subjects were 44 registered nurses working on a telemetry unit or on a medical intensive care unit. Our study has shown that, while there was no significant difference between overall scores on the three measures, there was a significant difference between the scores of actual clinical placement on patients and simulated clinical placement on a model for the subscale for chest lead placement, with actual clinical placement scores being lower. Further, while there was no significant difference among groups, the mean scores indicated that the electrode placement is not accurate by any method. These findings have implications for the application of knowledge to actual clinical practice and for the accountability of nurses for correct electrode place on their patients.